Some links and readings posted by Gary B. Rollman, Emeritus Professor of Psychology, University of Western Ontario

Wednesday, January 4, 2012

Nowhere to Go, Patients Linger in Hospitals, at a High Cost - NYTimes.com

Hundreds of patients have been languishing for months or even years in New York City hospitals, despite being well enough to be sent home or to nursing centers for less-expensive care, because they are illegal immigrants or lack sufficient insurance or appropriate housing.

As a result, hospitals are absorbing the bill for millions of dollars in unreimbursed expenses annually while the patients, trapped in bureaucratic limbo, are sometimes deprived of services that could be provided elsewhere at a small fraction of the cost.

"Many of those individuals no longer need that care, but because they have no resources and many have no family here, we, unfortunately, are caring for them in a much more expensive setting than necessary based on their clinical need," said LaRay Brown, a senior vice president for the city's Health and Hospitals Corporation. Under state law, public hospitals are not allowed to discharge patients to shelters or to the street.

Medicaid often pays for emergency care for illegal immigrants, but not for continuing care, and many hospitals in places with large concentrations of illegal immigrants, like Texas, California and Florida, face the quandary of where to send patients well enough to leave. Officials in New York City say they have many such patients who are draining money from the health system as the cost of keeping people in acute-care hospitals continues to escalate.

But even if Medicaid pays for some care, taxpayer dollars are ultimately being consumed by patients who could be cared for in nursing homes or other health facilities, and even at home if supportive services were available. Care for a patient languishing in a hospital can cost more than $100,000 a year, while care in a nursing home can cost $20,000 or less.

Patients fit to be discharged from hospitals but having no place to go typically remain more than five years, Ms. Brown said. She estimated that there were about 300 patients in such a predicament throughout the city, most in public hospitals or higher-priced skilled public nursing homes, though a smattering were in private hospitals.

One patient, a former hospital technician from Queens, has lived at the city's Coler-Goldwater Specialty Hospital and Nursing Facility on Roosevelt Island for 13 years because the hospital has no place to send him, Ms. Brown said. The patient, who is in his mid-60s, has been there since an arterial disease cost him part of one leg below the knee and left him in a wheelchair. The city's public health system declined to provide the names of any long-term patients or make them available for interviews, citing confidentiality laws.

Five years ago, Yu Kang Fu, 58, who lived in Flushing, Queens, and was a cook at a Chinese restaurant in New Jersey, was dropped off by his boss at New York Downtown Hospital, a private institution in Manhattan, complaining of a severe headache. Mr. Yu was admitted to the intensive-care unit with a stroke.

Within days, he was well enough for hospital personnel to begin planning for his release, but as an illegal immigrant (he had overstayed a work visa a decade ago), he was ineligible for health benefits. And no nursing home or rehabilitation center would take him. Neither would his son in China nor the Chinese government, although the hospital volunteered to fly him there at its expense.

Mr. Yu remained in the hospital for over four years until he was transferred last spring to the Atlantis Rehabilitation and Residential Health Care Facility, a private center in Fort Greene, Brooklyn, after the federal government certified him as a "permanent resident under color of law," essentially acknowledging that he could not be returned to China and qualifying him for medical benefits.

"This gentleman cost us millions of dollars," said Jeffrey Menkes, the president of New York Downtown. "We try to provide physical, occupational therapy, but this is an acute-care hospital. This patient shouldn't be here."

Mr. Yu said that the hospital had treated him well, but that he had made enormous progress in regaining his ability to walk through his rehabilitation regimen at Atlantis. He hopes to return to China when he is well enough to be discharged.

"Here, I am very happy," he said. "This is very nice — No. 1."

New York Downtown serves a largely immigrant population, and many patients have no insurance or proof that they are in the United States legally, which is necessary for discharge purposes and eventual reimbursements, said Chui Man Lai, assistant vice president of patient services at the hospital.

"These patients often arrive in the emergency room acutely ill and unaccompanied, and we have to treat them until they can be discharged safely," Ms. Lai said. "The hospital is required, by law and its mission, to care for these patients."

Health professionals refer to them as "permanent patients," trussed in red tape and essentially living in hospitals already operating on thin margins. In some cases, health care professionals say, grown children leave ailing parents at the hospitals and go on vacation. Officials call that practice a "pop drop."

Though the problem is particularly severe in the municipal hospital system, longtime patients place a financial burden wherever they end up.

New York Downtown spends about $2 million annually for such patients out of an operating budget of about $200 million. An acute-care patient can cost the hospital more than $1,500 a day.

Hospitals are reluctant to complain publicly about such patients for fear of being perceived as callously seeking to dump nonpaying patients. Elected officials are generally loath to be seen as encouraging illegal immigrants by changing reimbursement formulas. The issue was never addressed during the debate over national health care legislation.

Longtime patients, meanwhile, risk getting sicker because they are exposed to diseases that fester in hospitals.

"At times there is a fine line regarding who meets the criteria to be admitted to a hospital, but if there's no way to immediately contact a family member and the patient needs nonmedical help or is homeless, you're obligated to provide shelter," said Dr. Warren B. Licht, who recently retired as New York Downtown's chief medical officer after seven years to return to full-time clinical practice in the wellness and prevention center that he founded there. "You can't kick a patient out of the hospital."

New York Downtown, Dr. Licht said, has offered to pay for nursing home care for patents who are uninsured and are illegal immigrants, but care facilities are reluctant to risk taking patients for fear that they would be saddled with unexpected and unreimbursed expenses.

"If the patient does not have or cannot obtain health insurance to pay for the next level of care, other non-acute-care health facilities won't routinely accept a patient," Dr. Licht said.

New York Downtown has four or five patients out of a total of 180 who have no place to go, he said, adding, "It cost us several million dollars a year in a hospital struggling to keep its head above water."